A Medical Claims Processor or Representative reviews and processes medical insurance claims and determines whether an insurance policy will cover a medical procedure. Gathers information from policy holders and organizes insurance files; may process checks with payments to policy holders when a medical claim is approved.
The primary function of the Prior Authorization Specialist is to support the physician and interdisciplinary team in facilitating patient care with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. .
RESPONSIBILITIES AND ACCOUNTABILITIES
Efficiently obtain authorizations for procedures to be performed prior to patients being scheduled. Verify insurance for in-network or out-of-network eligibility and benefits. Pre-certify services include surgery, office visits, diagnostic testing, and any procedure that requires authorization. Maintain referral and authorization record documentation. Consult with physicians, nurses, staff and providers regarding the referral and pre-certification process. Monitor outstanding authorization requests and initiate follow up of outstanding authorizations in a timely manner. Prepare and submit appeals on behalf of patients. Accept, handle, and process incoming patient telephone inquiries using appropriate customer services skills. Assists in routine clerical functions such as faxing, scanning, and updating patient records. Communicate with patients to obtain information required to process prescriptions, refills, access benefits and authorizations. Obtain prior authorizations; initiate request, follow up to provide additionally required information, track progress, and expedite responses from insurance carriers and other payers, and maintain contact with customers to keep them continuously informed. Review for accuracy of prescribed treatment regimen prior to submission of authorization. Facilitate appeals process between the patient, physician and insurance company if needed. Composes clinical appeals letters based on specific denial reason and patients' clinical presentation. Ensures all clinical information and documentation are obtained prior to appeal submission. Completes status check with insurance company regarding receipt of prior authorization and appeal and approval or denial. Track, report, and escalate service issues arising from requests for authorizations, financial assistance or other issues that delay services. Works closely with Clinic staff, Admitting, Case Management, and Surgery Department. Performs other related duties as requested or assigned.
EDUCATION/QUALIFICATIONS/EXPERIENCE
Requires an LPN License in the State of Louisiana. BLS Certification required upon hire. MOAB Certification preferred Equal Employment Opportunity Statement It is the policy of Bayou Bend Health System to provide equal opportunity to all employees and applicants without regard to race, color, religion, national origin, sex, age, disability, or any other regard as required by law. This policy relates to recruitment, employment, placement, layoffs and recall, promotion/demotion, discipline, transfer, termination, rates of pay and/or all other forms of compensation, training and development, use of facilities, and participation in hospital sponsored activities. Drug Testing Bayou Bend Health System is an alcohol and drug free workplace. As a condition of employment all candidates must undergo and pass a post-offer drug screen. Failure to participate in the mandatory drug screen will void all offers of employment.
